Transcript
Sanitary Situation Survey
1. Community ______________________________________________________________ 2. Address _________________________________________________________________ 3. Property Owner_____________________________ Phone #______________________ 4. Plat Map Identifier ________________
Acreage ______ Age of Home _______years
5. How long have you lived here? ________years 6. How many bedrooms are in your home? ________
How many live in your home?______
7. Does your home have any of the following: washing machine
garbage disposal
hot tub or spa
8. Is your washing machine connected to the septic system?
in-ground lawn sprinkler
Yes
No
If “No” where does it drain? _______________________________________________ 9. Is your hot tub or spa connected to the septic system?
Yes
No
If “No” where does it drain? _______________________________________________ 10.
Do you know approximately where your septic system is located?
Yes
No
11.
Is there parking or driving over any part of your septic system?
Yes
No
12. Where does your drinking water come from?
Shared well 13.
14.
Private well
Other____________________________________________
About how old is your septic system? 11-20 years
Public system
0-5 years
More than 20 years
6-10 years
Don’t know
Have you ever had your septic system repaired?
Yes
No
Don’t know
If “Yes” what was done? _____________________________________________ _____________________ 15.
How much did it cost? ________________
Have you noticed any of the following conditions related to your septic system: Wetness in yard (unrelated to rain)
Septic discharge
Strong sewerage smell in yard
Slow drainage of your plumbing
Sewage back-ups into home
Well water test shows positive for Fecal Coliform bacteria
16.
When was the last time that your septic tank was pumped_________, and how much did it cost__________? How often do you have it pumped? __________________
17.
Do you have a water softener?
Yes
No
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Sanitary Situation Survey 18.
Would you support the formation of a wastewater utility that would care for the maintenance, repair, and even replacement of your septic system?
Yes
No
If “Yes”, how much money would you be willing to pay, per month for this service? $0 19.
$5
$10
$15
$20
Map: Show with approximate distances (in feet): buildings, driveways, roads, wells, septic tank, drainfield, ditches, and ponds, etc.
KEY Building : Drainfield : -----DF-----Septic tank : ST Well : W ___________________ 30 feet
NORTH
How far away is the closest drainage ditch (as the crow flies)? Are there areas or lines of greener, taller grass in the yard?
Less than 100 ft No
Signature of Surveyor 1 ________________________________________________
Signature of Property Owner
Half mile or more
Yes (show on map: GGR)
Are there any wet or spongy places in the yard that have a sewage odor?
_________________________________________
A few hundred yds
No
Yes (show on map: SP)
____________________________________
Signature of Surveyor 2 ___________________________
Date
2